An assessment of health promotion capability in PHOs. Written by Sarah Widmer on behalf of the Public Health Association

Transcription

1 An assessment of health promotion capability in PHOs Written by Sarah Widmer on behalf of the Public Health Association 2011

2 Table of contents Executive summary and recommendations Introduction Background Method Results Frameworks influencing health promotion practice Contextual influences on health promotion in a primary care setting Organisational capabilities that influence health promotion in a primary care setting Aspects of health promotion capability that need to be developed Discussion and recommendations Develop capability in health promotion frameworks Support broader developments of health promotion in primary care Support the transition of health promotion in the current primary care environment Recommendations References Appendix A: Question schedule

3 Executive summary and recommendations Few assessments have been conducted about health promotion capability across PHOs to date. Identifying this capability is important to determine next steps for health promotion in a primary care setting. This is a particularly critical period for such an assessment as the direction of primary care is changing. This project aims to identify PHOs interest in developing their public health capability. In particular, this project seeks to better understand: 1. tools, frameworks and concepts that have assisted each PHO in its health promotion programmes 2. organisational and individual capability in applying various tools/concepts in their work 3. the aspect of health promotion capability PHOs are most interested in developing. To conduct this research, semi-structured phone interviews were conducted with health promoters and/or health promotion managers from selected PHOs across New Zealand. In total, 10 interviews were conducted with 5 PHOs and 3 organisations contracted by PHOs to deliver health promotion services. The focus of the interviews was on work that health promoters (or managers) were responsible for, rather than all the work within their organisation that could be classified as health promotion. The main themes that arose in the research were around: frameworks influencing health promotion in practice contextual influences on health promotion capability in a primary care setting organisational capabilities influencing health promotion in a primary care setting aspects of health promotion capability that need to be developed. Frameworks influencing health promotion in practice Overall, all respondents demonstrated general knowledge of health promoting frameworks such as the Ottawa Charter and Te Pae Māhutonga. Most drew on these tools when planning their work, as well as when reporting and communicating to others what health promotion is. The extent to which these frameworks influenced their planning compared with other influences, such as governance directives is unclear. Respondents also seemed to have varied skills in different strands of the Ottawa Charter or Te Pae Māhutonga. Half of respondents tried to work on all strands of the Ottawa Charter. However, respondents also reported that many health promoters come from strong community backgrounds but lack skills in working on strategies to improve healthy public policy or reorient health services. In addition, while four respondents mentioned they used Te Pae Māhutonga as a planning tool, the remainder of participants did not discuss ways they consider working with Māori within te ao Māori. Most respondents also did not know about ProCare PHO s Health Promoting Practices Quality Framework, which was developed for the PHO 3

4 setting and provides a template developed for expanding primary health care to include a comprehensive health promotion and population health perspective. Contextual influences on health promotion capability Most respondents described changing circumstances with the type and focus of their health promotion activity although this was not an explicit question. These changes were primarily due to resource cuts; and an increasing accountability of health promotion activity towards the PHO s broader accountabilities. Most organisations had had cuts to their number of health promotion contracts and/or health promotion FTE. Most had been amalgamated in the previous year. Respondents also highlighted that in some PHOs, the emphasis of health promotion was shifting towards programmes that directly related to national health targets, PPP indicators and other PHO priorities. In some instances, health promoters were told to refine their work around these areas, meaning less flexibility to work on communitybased initiatives and a greater focus on supporting GP practices. In other instances, health promoters were aware their positions were going to be disestablished and funding spread across GP practices. These changes were not universal to respondents, but did reflect a common theme. Organisational capabilities influencing health promotion Participants were asked what organisational capabilities have supported their health promotion programmes. Responses centred on: Management/governance that understand the value of health promotion this knowledge made them supportive of health promotion and gave health promotion credibility within the organisation Skilled health promotion practitioners many described their way of working, which illustrated health promotion principles in action Connected PHO structures strong connections between various parts of their organisation as an asset to their work, including use of specialist clinical or other advisors Use of PHO infrastructure including basic infrastructure (cars, computers) as well as IT infrastructure (up-to-date information on their enrolled populations to better target health promotion initiatives) The barriers to respondents work largely reflected an absence of these capabilities. The most common barriers were: lack of understanding of health promotion among Board members or other parts of the PHO, lack of health promotion skills in working on all aspects of the Ottawa Charter (including in reorienting health services), and lack of clarity among health promoters and others in articulating clear outcomes for health promotion programmes. Aspects of health promotion capability that need to be developed Individuals were asked about ways that health promotion capability could be strengthened within their organisation. All respondents articulated that while health promotion capacity had reduced, greater understanding and support for health promotion among the various parts of their organisation was important. Similar to 4

5 respondents description of organisational capability, their ideas for capability development centred on better understanding of health promotion among the wider PHO, and better understanding of wider PHO activity among health promoters. Discussion The findings illustrate a diverse experience and ability of health promoters in using various frameworks to full benefit. They also illustrate the wide range of PHOs and PHO priorities. The findings highlight the need for: increased training and skill development to ensure health promoters have a full range of competencies training in a primary care health promotion framework, such as ProCare PHO s Health Promoting Practices Quality Framework, because it provides a guide for developing a health promoting approach across a PHO (this is particularly important as there seems to be a trend towards health promotion activity focusing primarily on the practice setting) strong regional health promotion networks to support health promoters in developing competencies and exchanging strategies for developing and implementing health promotion programmes, including ones around PPP indicators and health targets. continued/increased understanding of health promotion among PHO Boards, managers and clinical leaders, particularly as PHOs are rapidly amalgamating and their governance and leadership is changing. The ProCare framework has the potential to be a vehicle for generating this understanding. health promotion as a profession to articulate its connection to current primary health targets and priorities, so that the value of health promotion is clear even if the type of health promotion activities occurring with the PHO are changing. There is a risk that health promotion activity will dissipate as the role of health promotion within PHOs seems to be changing. The challenge is to maintain sufficient health promotion expertise in spite of the change in focus, and to ensure health promotion has an influence in the new direction. Recommendations 1. Ministry of Health/Health Workforce NZ to maintain funding for health promotion training and competency development via the Health Promotion Forum. 2. Ministry of Health to fund Health Promotion Forum and ProCare to provide training in the ProCare Health Promoting Practices Quality Framework (This recommendation links to Recommendation 1, but would require additional funding than what is already provided to the Health Promotion Forum). 3. Ministry of Health to fund an advisory role to: articulate the connection between health promotion and current health priorities; assist health promoters in primary care in building an understanding of working within the PHO setting to reorient health services ; and support regional health promotion networks. 5

6 1. Introduction Health promotion practice within a primary care setting has been formalised relatively recently in New Zealand. With the inception of the Primary Health Care Strategy in 2001, PHOs became responsible for delivering health promotion services as part of comprehensive primary health care delivery. With ring-fenced health promotion contracts, PHOs have been required to develop health promotion plans to illustrate how health promotion will underpin and influence other activities of the PHO to improve health outcomes and reduce inequalities for enrolled populations. Few assessments have been conducted about health promotion capability across PHOs to date. Identifying this capability is important to determine next steps for health promotion in a primary care setting. This is a particularly critical period for such an assessment as the direction of primary care is changing. There is a strong emphasis on clinical leadership and governance, PHOs are rapidly amalgamating, and PHOs are involved in a number of government initiatives, such as Better, Sooner More Convenient Primary Health Care, Integrated Family Health Centres and Whānau Ora. All of these changes have implications for health promotion practice in primary care. This project aims to identify PHOs interest in developing their public health capability. Although public health within PHOs is wider than health promotion, the focus of this project is on health promotion and health promoters within PHOs. This project seeks to better understand the broad enablers of and influences on health promotion capability in PHOs, including: 1. tools, frameworks and concepts that have assisted each PHO in its health promotion programmes 2. organisational and individual capability in applying various tools/concepts in their work 3. aspects of health promotion capability PHOs are most interested in developing. Rather than being an assessment of all PHOs health promotion practice and capability, it surveys a small number of health promoters and managers in PHOs across New Zealand. This paper presents the results of this qualitative assessment and discusses the implications for health promotion practice. 2. Background PHOs vary in the nature of their health promotion work. Thomas (2010) asserts that some PHOs evolved out of a community centric primary care paradigm and others out of a traditional/biomedial primary care paradigm. These origins have carried through to their approach to health promotion. PHOs have also had 6

7 diverse governance and leadership structures, relationships with DHBs and communities, and approaches to the use of health promotion funding (Thomas, 2010). The Ministry of Health, public health units, and others have provided guidance around health promotion practice in primary care settings (for example, Ministry of Health, 2003; Auckland Regional Public Health Service, 2005). Public health and primary care (and to a lesser extent, health promotion in primary care) has also been the topic of numerous pieces of research (for example, Crampton, 2004; Winnard et al, 2008; Love & McLeod, 2002). In spite of this guidance, most of the health promotion frameworks and tools that exist in New Zealand are not specific to health promotion practice in a primary care setting. Ottawa Charter, Te Pae Māhutonga, and Whare Tapa Whā are all models that apply to health promotion practice in all settings. The advantage of these frameworks is they are adaptable. However, it can be difficult for health promoters to interpret how to apply such frameworks in a primary care setting. In 2006, Procare Health Ltd PHO developed a Health Promoting Practices Quality Framework based on the World Health Organization s health promoting hospitals philosophy. The Framework provides a template for expanding primary health care to include a comprehensive health promotion and population health perspective, and improve primary care clinicians knowledge of health promotion. The framework provides guidance on implementing a spectrum of health promotion activities that have links to general practice, including: improving systems for delivering health information and education, adopting healthy workplace practices, linking to social marketing campaigns and messages, improving community participation, and improving clinicians understanding and engagement in healthy public policy. Procare piloted the framework and accompanying toolkit in over 10 clinics and is reviewing results of these pilots. 3. Method To conduct this research, semi-structured phone interviews were conducted with health promoters and/or health promotion managers from selected PHOs across New Zealand. To identify potential PHOs for the project, a list of the largest PHOs, Māori provider organisations and Pacific provider organisations were obtained. Their websites were searched to determine which of them provided health promotion services and had designated health promoters. Invitations to participate in the research were then sent by or phone to 12 PHOs or organisations that deliver health promotion services on behalf of PHOs (as of July 2011, there were a total of 32 PHOs across New Zealand). Interviewers were provided with a brief overview of the research, and assured that their responses would remain confidential. Responses were heard from 9 of the 12 organisations (6 PHOs and 3 organisations contracted by PHOs to deliver their health promotion services). 7

8 In total, 10 interviews were conducted with 5 PHOs and 3 organisations contracted by PHOs to deliver health promotion services. One PHO had recently amalgamated so two interviews were conducted with different branches of the PHO. In another PHO, an interview was conducted with both the health promoter and manager. Of the 10 interviews, 7 interviews were with health promoters and three with managers of health promotion teams. Two of the interviews were with a Māori provider or Māori PHO and one with a Pacific provider for a Pacific PHO. Nine of the interviews were with North Island PHOs and organisations, and one with a South Island PHO. The range in the enrolled populations for these PHOs was 7,500 to 300,000. Each interview lasted approximately 30 minutes, using questions in Appendix A as a guide. Notes were taken during the phone interviews, and analysed for themes. 4. Results The main themes that arose in the research were around: 1. frameworks influencing health promotion in practice 2. contextual influences on health promotion capability in a primary care setting 3. organisational capabilities influencing health promotion in a primary care setting 4. aspects of health promotion capability that need to be developed. Most respondents described the health promotion work that they as health promoters (or managers) were responsible for, rather than all the work within their organisation that could be classified as health promotion. So for example, most did not discuss one-on-one prevention efforts that GPs or practice nurses were doing with clients that would fall under the umbrella of health promotion. 4.1 Frameworks influencing health promotion practice Frameworks used in practice Participants were asked about the health promotion frameworks or concepts that are used within their organisation. All respondents noted they use health promotion frameworks to some degree in their work, particularly in programme planning. The specific tools or concepts mentioned by respondents were: Ottawa Charter (8 respondents) Te Pae Māhutonga (4 respondents) Council, DHB and Ministry strategies (4) 8

9 Treaty of Waitangi (3) Whare Tapa Whā (2) logic planning around the quality of service delivery (1) Tuhanz (A Treaty understanding of Hauora in Aotearoa-New Zealand) (1) Participants were asked whether they had heard of Procare PHO s Health Promoting Practices Quality Framework. Three respondents said they had heard of it; only two had worked with the framework and both of these were from upper North Island organisations. These two respondents said they found elements of the framework useful and applied it in their work. However, both respondents had reservations with the current version of the framework. One found the overall framework too intensive, and the other said it was not appropriate for PHOs whose clinicians were not fixed in one practice. The intent of it [Procare framework] is great, but implementation is where it will be key. There s still some debate whether the concept is valid it takes a long time to complete it d be better to undertake 1-2 small programmes [of the framework] in a practice and see how it goes. It is unclear whether they would have used the framework more were it to be scaled down and adapted for a range of primary care settings. It also appears that these issues were with implementation rather than the framework per se. Respondents explained that the various health promotion frameworks help them in developing comprehensive strategies. Many noted they aim to work on programmes that cover all aspects of frameworks such as the Ottawa Charter. When we write a plan and look at interventions, we use the Ottawa Charter a lot. One respondent said that Te Pae Māhutonga was used as an effective regional planning tool for breast screening and helped the planning group identify strategies to cover all of its strands. For example, they identified access to screening as an issue that related to the strand, participation, and so developed an activity around cell phone messaging. Two respondents said they use these frameworks as a reporting tool. Some respondents said that the Ottawa Charter is used to define health promotion to clinicians, other agencies or the Board. The Ottawa Charter is well used. It sits in the background. I often use it as a tool to explain what health promotion is. MāhutongaAll respondents said that these frameworks are primarily used by health promoters, rather than by other health practitioners or managers. However, one respondent acknowledged that while other parts of the PHO such 9

10 as outreach nurses and immunisation coordinators may not use health promotion language, their work focuses on social determinants and reducing inequalities. She noted that practice nurses and GPs in her PHO had been trained in health promotion, and the Ottawa Charter was a key element of this training. Two respondents emphasised the same with health promotion training for their Boards. The extent to which respondents said they relied on these health promotion frameworks in their work varied. While most respondents said they used the frameworks to a degree, not all explained how actively they were actually used. One respondent acknowledged she rarely used the Ottawa Charter, because she was more guided by community feedback and priorities. I respond to the needs of the community. I find out what they want and what they want to achieve. Another respondent said she relies heavily on health promotion frameworks like the Ottawa Charter, but emphasised that partnership was also important: the biggest thing is partnership. We must ensure we have strong collaboration to build policy and to get things done. Yet another respondent commented that in spite of using these frameworks in practice, accountabilities to wider PHO priorities were increasingly shaping his work: At the end of the day, if I m told to work towards the PPP indicators, then these will drive what we do. He said he used to use the Ottawa Charter more in planning and reporting when his work was not confined to working on particular activities. Aspects of frameworks most relevant to a primary care setting In discussing the health promotion frameworks used within their PHO, participants were asked which strand of the Ottawa Charter 1 was most relevant or effective because they were working from a primary care setting. A summary of responses is provided in the table below, with some people giving more than one answer. 1 The strands of the Ottawa Charter are: build healthy public policy, create supportive environments, strengthen community action, develop personal skills and reorient health services. 10

11 Ottawa Charter strand most effective/relevant Number of responses All strands 5 No strands 1 Build healthy public policy 0 Create supportive environments 1 Strengthen community action 3 Develop personal skills 1 Reorient health services 2 Half of respondents said that they tried to use all strands because they aim to work in a comprehensive way. One respondent highlighted that creating supportive environments was the most effective strand for her work, because her PHO had positive name recognition. She felt she could use this recognition to have an influence in inter-agency initiatives. Another respondent highlighted that developing personal skills was the most relevant strand for her work, because this is where the greatest amount of health promotion funding was directed, compared with funding related to other Ottawa Charter strands. Three respondents explained that supporting community action was the most relevant to their work. Reasons given were their links to the community, their commitment to community engagement and the relatively high amount of health promotion funding going to community-based efforts. We always go back to the local community and ask what they want. One respondent acknowledged that community action was the most appropriate for PHOs that have a community-based foundation. However she reflected that her PHO has a strong clinical, business focus, so reorienting health services was the most relevant strand for her work because she was based in a health service setting. You have to make health promotion work in different settings. Health promotion in a clinical setting will be different than health promotion from, say, a public health unit. In a clinical setting, reorienting health services is important. That s the opportunity and that s the setting. Another respondent described reorienting health services as the most relevant strand for his work, but this was because of a governance directive. He explained that he and other health promoters in other PHOs have been asked to stop community-based work in order to focus on health promotion efforts within GP practices. Previously we did a lot of work with marae and community-based work, but now our strategies are more within the GP/primary care setting People involved in funding want to push health promotion efforts to screening and early intervention because that will add value to their work. 11

12 Some respondents described that health promoters are not skilled in working on all strands of the Ottawa Charter, and that this influences the focus of their work. One person reflected that reorienting health services is often ignored by health promoters in PHOs because it is considered too hard and/or promoters are not skilled in working with clinicians. A manager said she emphasised the importance of all Ottawa Charter strands with her staff, but that many of her health promoters are not initially skilled in working on all strands: Where we draw the workforce from means they have strong community networks but don t have policy expertise. With the workforce, it s about me [as a manager] providing them with the best possible start in these other areas. Another manager acknowledged that most of her staff also have a strong community background, compared with other aspects of the Ottawa Charter. She explained that these foundations were an asset to their work. 4.2 Contextual influences on health promotion in a primary care setting Most respondents described changing circumstances with the type and focus of their health promotion work although this was not an explicit question. These changes were primarily due to resource cuts; and an increasing accountability of health promotion activity towards the PHO s broader accountabilities. In general, individuals emphasised greater pressures and less flexibility with the scope of their work in recent months, although there were a couple exceptions. Resource cuts Many of the respondents interviewed were in a state of change with the health promotion services they were delivering. Most organisations had had cuts to their number of health promotion contracts and/or health promotion FTE. One respondent said her position was going to be dissolved, with funding divided across practices. Seven of the 10 interviews were with PHOs and organisations that had been amalgamated in the previous year. Resource cuts meant in many instances that the organisations health promotion work was spread across fewer topics or projects. Greater health promotion accountability to overall PHO accountabilities The other major influence on health promoters work was greater accountability to the PHOs overall accountabilities. This change was not necessarily a shift in the original policy intent of health promotion s place in PHOs, but for many has meant a change to their practice. 12

13 Some respondents described strong mandates coming from PHO Boards and governing bodies to narrow their focus on efforts directly related to PPP indicators, internal priorities or national health targets. This shift was from a range of policy and community-development projects that both directly and indirectly related to priority health outcomes, to a more narrow focus on supporting activities occurring within GP practices. Five respondents said they are held accountable to showing direct links to these priorities. Health promotion must now only address PHO performance indicators and the priorities of the Whānau Ora business case. We have to justify how we will meet national health targets in a succinct and measurable way. Two respondents were part of PHOs that were Whānau Ora providers and at least two were associated with integrated family health centres. These respondents described the influence of these initiatives on their work. The Better, Sooner, More Convenient business plans created a whole new change in direction for the PHO, including health promotion. This shift was not universal. Some did not comment on a change in direction, and two respondents said their work was not changing. One person acknowledged the influence of national and PHO health targets, but indicated she had some flexibility to work on other topics, such as family violence, because her CEO understood social determinants of health. The other person was a manager with a health promotion background, who explained that she s worked hard not to have health promotion fundamentally shift in her team. Health promotion is not changing in my team, but that s because of my foundations. It s how I direct the team and keep it real with health promotion. Respondents said the change in focus wasn t negative per se, in that there is value in ensuring preventive clinical efforts such as screening and immunisation take a health promotion approach. However, some noted it did present a risk for health promoters if the shift in funding or directive was not done in a considered way. The challenge will be on the workforce to advocate for upstream areas and show that there s value in adding these approaches. Health promoters need to say where we can add value. The money is shifting from health promotion to clinical settings, and we need to think about how to add to this. There is a risk of losing values and approaches of the way of doing health promotion with this shift. Unless we have a group of people who are focused on the health promotion aspects of this shift, the money may devolve to providers and get lost. 13

14 4.3 Organisational capabilities that influence health promotion in a primary care setting Participants were asked what organisational capabilities have supported their health promotion programmes. Responses centred on: Management/governance that understand the value of health promotion Skilled health promotion practitioners Connected PHO structures Use of PHO infrastructure Participants were not directly asked about barriers to achieving health promotion programmes in a primary care setting. However, the barriers that they did describe related to an absence of these capabilities. Management/governance that understands the value of health promotion The most common response to organisational capability was having a manager, Board and/or CEO with knowledge in health promotion, identified by four participants. As previously described, CEOs and managers who understood health promotion and determinants of health showed greater support for a wider range of health promotion initiatives. Participants also described that CEOs, Board members and managers strong knowledge of health promotion gave health promotion credibility within the organisation. Because the Board was trained in health promotion, they have an appreciation for it when we are applying for funding. Both the previous CEO and the current acting CEO are willing and accepting of health promotion. This is useful for my work in the community, and it also gives health promotion validity within the organisation. My manager understands it and is helpful. In contrast, lack of understanding of health promotion among Board members or other parts of the PHO was identified by other respondents as a major barrier to their work. Four people explained that many still confuse health promotion with health education, in spite of efforts to explain that it is more than just posters and flyers. This confusion reduced the relative value placed on health promotion in the PHO. It is always difficult to have a health promotion approach within a PHO that s given the same level of importance as other parts of PHO practice. 14

15 One respondent described that the clinical advisor who was the point of contact for working with the GP practices did not have a strong understanding of health promotion, so health promoters were limited in what got communicated to practices. To address this lack of knowledge, some respondents talked about projects they and others had done to train their Board and GP practices about health promotion. These have led to positive results. One respondent described a training she organised for practice nurses and GPs about health promotion. At the end of the training, practices received some funding to develop a project around improving access to services in their practice. She reflected that the training meant practices now have a greater appreciation for health promotion as well as a broader approach to working with and improving access for clients. Skilled health promotion practitioners Respondents did not talk much about their own particular health promotion skills. However, some referred to their way of working, which illustrated health promotion principles in action. In particular, five respondents highlighted the importance of strong relationships with agencies, communities and other parts of their organisation when implementing health promotion programmes. Some respondents had strong community links and emphasised the importance of these relationships both to inform health promotion programmes and in reaching target populations. Strong partnerships with referring organisations is important. This way of working reflects a mediating and enabling approach, which underpins the Ottawa Charter. Others description of specific projects, such as the previously described training with GP practices and activities to promote breast screening, illustrate respondents skills in developing a health promotion approach within a primary care setting. At the same time that many demonstrated health promotion skills, inconsistent health promotion skills across the health promotion workforce was a common theme among respondents. Four respondents described that health promoters as a workforce have varying expertise in health promotion. They noted that many health promoters come from the community and may not understand how to work with clinicians or how to influence public policy. One manager highlighted the importance of enrolling new staff in the health promotion certificate programme. Two others talked about the need to upskill health promotion staff in working with clinicians. The health promotion workforce needs to be adaptable. Many health promoters do not have experience working with GPs and clinically oriented people. 15

16 Five people described the lack of clarity that exists (among health promoters and others) in articulating clear outcomes for health promotion programmes. When working in health, you recognise the benefits of health promotion. When you work in government, it s hard to see that. It s often hard to articulate what you re trying to achieve in health promotion. Many endorsed the health promotion competencies coming out of the Health Promotion Forum as a way to give guidance to health promotion capacity building. A couple respondents described the need for the health promotion profession to sharpen its focus and communicate its relevance to current health priorities. The profession hasn t done itself favours in creating understanding across organisations and the Ministry [of Health] in the past. Anything that can tighten up health promotion and add value is good. Connected PHO structures Respondents described strong connections between various parts of their organisation as an asset to their work. In some instances, the connection strengthened other health practitioners understanding of health promotion. In other instances, the connection opened up the door to working with different parts of the PHO. We work as a small team because we are in a small area, so all staff are aware of health promotion. We fit together like a jigsaw. Someone who has a connection with practice liaison teams is always vital. The importance of specialist advisors to bridge or strengthen aspects of health promotion programmes was highlighted as an aspect of this connectivity. Four respondents described the value of advisors including: tikanga advisors for creating good relationships with marae and iwi in the region clinical advisors or practice liaison teams who are points of contact with practices we have a team of clinical facilitators who are the vehicles for working with practices. That set up seems to work well. and a physical activity advisor to bring together the physiological, health promotion and physical education aspects needed to develop a comprehensive health promotion programme. 16

17 Use of PHO infrastructure Finally, five respondents described the importance of basic infrastructure, including cars for those in rural areas, and computers. Three respondents particularly emphasised IT infrastructure as an aid to their programmes. This has enabled respondents to have up-to-date information on their enrolled populations and target health promotion initiatives to populations in need. A strong IT team is good for providing timely information on cervical screening and immunisation. That way we can hone in on the areas where not many are immunised or screened. One respondent noted that access to information about enrolled populations was an asset for her in developing projects, noting it was not something that health promoters in other settings could do. She pulled data on Māori and Pacific clients who had not had breast screening and organised a promotional evening for them where they were able to get screened, and also receive other interventions such as tetanus immunisation and cervical screening. 4.4 Aspects of health promotion capability that need to be developed Individuals were asked about ways that health promotion capability could be strengthened within their organisation. All respondents articulated that while health promotion capacity had reduced, greater understanding and support for health promotion among the various parts of their organisation was important. Similar to respondents reflection on organisational capability, their ideas for capability development centred on: Better understanding of health promotion among the wider PHO Better understanding of wider PHO activity among health promoters Better understanding of health promotion among the wider PHO Responding to the lack of health promotion understanding that still exists among management and governance, three people described the need to better inform their Board, CEOs and management about health promotion. This information would lead to greater support for their work and understanding that all outcomes may not as measurable and immediate as many clinical interventions. More training, more updating, getting other people on board, including upper management so they understand it. Some respondents also indicated the need to strengthen knowledge of health promotion among clinicians and organisations that PHOs are funding. The health promotion training for clinicians that is described in Section 4.3 is one example of how this gap was addressed. 17

18 Better understanding of wider PHO activity among health promoters Resources were being cut in health promotion, but many noted that they still receive support from their managers to attend relevant training or courses in health promotion. No respondents indicated that they would like more training in health promotion frameworks such as the Ottawa Charter, but two respondents indicated an interest in information about ProCare s Health Promoting Practices Quality Framework. Two respondents emphasised the need for health promoters to become more informed about how to work with clinicians and health practitioners in the health service. They described the different views of clinical and health promotion disciplines as a current point of tension. There needs to be a proactive marriage between clinical thinking and health promotion. There is currently friction in this area, but it doesn t need to be either/or. We must promote the importance of the two together. These respondents said this was an important area of capability development, particularly as they were increasingly being told to work with practices on health promotion activity. Three respondents described the need for health promotion to strengthen itself as a profession. They said that the profession should articulate its connection to the current national approach to primary health care, clarify practical outcomes that it is working towards, and recognise the value of health promoters in PHOs alongside health promoters in other settings. They emphasised that this clarity would support them in their work with their own PHOs. 5. Discussion and recommendations In this assessment, health promoters illustrated a continued enthusiasm and commitment to improving health outcomes for their enrolled populations. Their responses showed that while coming from diverse backgrounds and PHO settings, they share many health promotion competencies. This assessment has highlighted three levels in which health promotion capability can be further developed in primary care in the immediate future: 1. Develop capability in health promotion frameworks 2. Support broader developments of health promotion in primary care 3. Support the transition of health promotion in the current primary care environment 18

19 5.1 Develop capability in health promotion frameworks Overall, all respondents demonstrated general knowledge of health promoting frameworks such as the Ottawa Charter and Te Pae Māhutonga. Most drew on these tools when planning their work. The extent to which these frameworks influenced their planning compared with other influences, such as PHO mandates is unclear. Respondents also seemed to have varied skills in different strands of the Ottawa Charter or Te Pae Māhutonga. In particular, respondents reported that many health promoters come from strong community backgrounds and lack skills in working on strategies to improve healthy public policy or reorient health services. In addition, while four respondents mentioned they used Te Pae Māhutonga as a planning tool, the remainder of participants did not discuss ways they consider working with Māori within te ao Māori. Most respondents also did not know about ProCare PHO s Health Promoting Practices Quality Framework. The findings illustrate a diverse experience and ability of health promoters in using various frameworks to full benefit. This reflects anecdotal reports about the diversity of the sector as a whole. The wide range of PHOs and PHO priorities mean that not all health promoters may need to employ the full range of health promotion interventions. However, it is important to ensure that they have a full set of competencies, and that a lack of health promotion skills in certain areas does not dictate the focus of their work. The findings illustrate in at least a couple examples that this may have been the case. There is a need for continued training and skill development across the health promotion workforce. This includes training on: Multidisciplinary frameworks such as the Ottawa Charter Te Pae Māhutonga it is important to ensure that health promoters are meaningfully working with Māori and supporting Māori leadership through their programmes Procare Health Promoting Practices Quality Framework the apparent strength of the tool is that it is focused on a health promotion approach within a PHO setting. The Health Promotion Forum provides training for health promoters on a range of topics. They are also overseeing the development and roll out of health promotion competencies. Funding for training should be maintained to ensure greater attendance, coverage and progression through health promotion training. 19

20 5.2 Support broader developments of health promotion in primary care Progress has been made over the last decade in developing health promotion within a primary care setting. PHOs collectively have a wealth of experience in developing health promotion strategies to fit their settings and populations. Yet there remains considerable variety in the effectiveness of PHOs efforts to take a health promotion approach to their work. Responses from individuals interviewed indicate that the PHOs (and other primary care organisations) most supportive of health promotion have governing bodies, manager and clinical leaders who understand and appreciate the value of health promotion. As PHOs are rapidly amalgamating, their governance and leadership is also changing. In order for health promotion capability to be strengthened in primary care, there needs to be continued support for it among PHO Boards and clinical leaders. The ProCare Framework has the potential to be a vehicle for ensuring this continued support. The framework provides a guide for health promoters to work with different aspects of general practice to make sure the practices are health promoting. The framework also identifies health promotion champions in each practice, and calls for management responsibility as ways of ensuring activities are not just driven by health promoters. This approach is similar to that described by respondents who tended to focus their work on the PHO setting, in that there is a focus on the points of influence in a primary care setting and using multiple strands to increase the health promoting focus of the PHO. Those respondents who did know about the framework endorsed the concept, even though they highlighted some operational concerns around its intensity and applicability to all PHOs. There is a need for health promoters and managers to become more informed about the framework, so they can draw from it when working with clinicians and even governance. In addition, as the number and shape of health promotion positions is changing, a strong health promotion network for those working in primary care is crucial. A network would enable health promoters to exchange strategies for developing and implementing health promotion programmes, including ones around PPP indicators and health targets. The network could also be a vehicle for assisting health promoters to develop their health promotion competencies. 5.3 Support the transition of health promotion in the current primary care environment Respondents highlighted that in some PHOs, the emphasis was shifting towards health promotion activity that directly related to national health targets, PPP indicators and other PHO priorities. In some instances, health promoters were told to refine their work around these areas. In other instances, health promoters were aware their positions were going to be disestablished and 20

21 funding spread across GP practices. These changes were not universal to respondents, but did reflect a common theme. As this shift occurs in primary care, there is as risk of losing valuable expertise in developing comprehensive health promotion programmes in a primary care setting. There is also a risk that health promotion activity will dissipate. It appears from the interviews that the PHOs with less of a sense of the value of health promotion were using health promotion funding to increase practitioners efforts. The challenge is to maintain sufficient health promotion expertise in spite of the change in focus, and to ensure health promotion has an influence in the new direction. Thomas (2010) describes that current changes in primary care can be seen as an opportunity for health promotion. As PHOs become the site for a broader range of clinical services under integrated family health centres and Whanau Ora, health promoters can support PHOs in retaining the principles of a population health approach. Neuwelt et al (2009) identify the core features of a population health approach to primary care as: concern for equity, community participation, teamwork and attending to the determinants of health. There is potential for health promoters to assist PHOs in incorporating a concern for equity, community development approaches and concern for broader determinants in screening, immunisation promotion and other programmes focused on clinical priorities. This would ensure that while health promotion activities may change, the core principles underpinning the activities would not. For this shift to successfully occur, there is a need for health promoters to build their expertise in working with clinicians on health promotion programmes; lack of health promotion expertise in this area was identified by respondents. In addition, there is potential for health promotion as a profession to articulate its connection to current primary care health targets and priorities, including by drawing on these fundamental features of a population health approach. An advisory role to articulate health promotion s connection to primary care could support this shift. This advisory role could also support health promoters in their understanding and implementation of frameworks such as Procare, and support health promoters in participating in regional health promotion networks, described. This advisory role could sit in the Ministry of Health or Health Promotion Forum. 21

22 5.4 Recommendations 1. Ministry of Health/Health Workforce NZ to maintain funding for health promotion training and competency development via the Health Promotion Forum. 2. Ministry of Health to fund Health Promotion Forum and ProCare to provide training in the ProCare Health Promoting Practices Quality Framework (This recommendation links to Recommendation 1, but would require additional funding than what is already provided to the Health Promotion Forum). 3. Ministry of Health to fund an advisory role to: articulate the connection between health promotion and current health priorities; assist health promoters in primary care in building an understanding of working within the PHO setting to reorient health services support regional health promotion networks. 22

23 6. References Auckland Regional Public Health Service A guide to health promotion planning and action in PHOs. Auckland: Auckland Regional Public Health Service. Crampton, P The exceptional potential in each Primary Health Organisation: A public health perspective. Opinion piece for the National Health Committee. Love, T. & McLeod. D Perspectives on the delivery of population health services in primary care. New Zealand Family Physician 29: Ministry of Health A guide to developing health promotion programmes in primary care. Wellington: Ministry of Health. Neuwelt, P., Matheson, D., Arroll, B., Dowell, A. et al Putting population health into practice through primary health care. The New Zealand Medical Journal 122: Thomas, G The challenges and opportunities of primary care: A discussion paper for the health promotion workforce. Health Promotion Forum. Winnard, D. Cumming, J. Neuwelt, P. Et al Population health meaning in Aotearoa New Zealand? A discussion paper to support implementation of the Primary Health Care Strategy. 23